[Parkinson's disease: intrinsically palliative care]

Multidimensional, chronic, progressive and incurable, Parkinson's disease is, by definition, a palliative disease, and this from the moment of diagnosis. This vision, relatively new to neurology, calls for a paradigm shift, as well as a dual medical-paramedical and home-hospital alliance. This approach allows us to better understand the specificities of Parkinson's disease and its treatments in terms of palliative issues.

[From palliative care... to the palliative approach in paediatrics: 10 years on]

There are 24 regional pediatric palliative care resource teams (ERSP) in metropolitan and overseas France. An initial review of the ERSPs was carried out in 2015. The ERSP commission of the Société française de soins palliatifs pédiatriques (French Society for Pediatric Palliative Care) wanted to review the situation again, ten years after the creation of these teams. This article presents the main findings.

[Corneal donation and anticipatory care in palliative care]

Until now, the early approach of palliative care patients for corneal harvesting has been unheard of in France. At the Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges Lucie-et-Raymond-Aubrac, in the Val-de-Marne region of France, we offer a rigorous and respectful procedure and organization for patients who have been carefully selected for an early approach to donation.

[From one emotion to another, twenty-four hours in the life of a hospital doctor]

Every morning has its own mood: joy, sadness, annoyance, etc. Like all human beings, and beyond their professionalism, caregivers experience emotions throughout their day of practice. These emotions are both personal and professional. For example, the situation of a patient at the end of life, in an intensive care unit, will bring out different emotions in all the protagonists (patient, family, care team), narrated by the doctor in charge of the patient.

[The realities of hunger and thirst at the end of life]

Questions about nutrition and hydration are common in the context of the end of life. By end of life, we mean the terminal palliative phase, a particular period of organic fragility. These questions pose difficulties, insofar as the act of eating and drinking as a vital act has a symbolic, cultural and social dimension. They must be clarified with family members or even caregivers who are not familiar with these types of care.

[End of life at home, guiding relatives on what to do in case of dyspnea]

Respiratory difficulties presented by a loved one at the end of life at home can leave those around him or her unable to cope and lead to emergency hospitalizations that are not clinically justified in this context. This is why the educational role of nurses is so important. They contribute, through anticipated explanations and indications, to allow adapted attitudes likely to reduce anguish, even panic, and to make it possible to continue to live at home.

[living with our dead]

As a young cardiologist, Dr. Guillaume Bonnet was confronted with the end of life during a significant death that occurred during a shift in cardiological intensive care. Through his testimony, we can see the importance of freeing up speech, as well as ways of thinking about preparing physicians for such situations, particularly by highlighting the role of simulation.

[The taboo of the impact of end of life and death on caregivers]

The impact of the end of life and death on caregivers is not well known by institutions and by the professionals themselves. However, they are all confronted at some point with the death of one of their patients, which can lead to psychological trauma. There are, of course, associated personal and professional factors that can lead to anxiety, depression, burnout and even post-traumatic stress. The psychosocial consequences are underestimated, both for the caregiver and for the functioning of the teams, departments and hospitals (or practices), as well as for the quality of patient care. It is time to break the taboo of the impact of the end of life and death on health professionals, to bring them to work together on this issue and to encourage institutions to get involved.

[The time of agony, know, understand to inform and explain]

The agony, this pivotal moment, which is more or less long, before death, is very anxiety-provoking. When the person and his or her loved ones want this last stage of life to take place at home, healthcare professionals play an important role in providing clinical support to the patient and creating the conditions for relative emotional security for everyone. This requires clinical knowledge and interpersonal skills to explain what is happening to loved ones, to reassure them and to accompany the life that is passing away. A nurse referent in palliative care sheds light on the challenges of this specific multi-professional practice at home.

Mieux comprendre les besoins des personnes atteintes de cancer nécessitant des soins palliatifs et de fin de vie à domicile et les soins et services infirmiers offerts en milieu rural

Problématique

L’accès limité et inégal aux soins palliatifs et de fin de vie (SPFV) à domicile de même qu’à des professionnels qualifiés et à des soins et services infirmiers de qualité en milieu rural augmente les besoins non répondus dans l’ensemble de la trajectoire de soins des personnes atteintes de cancer.

Objectifs et méthodologie

L’étude propose un devis qualitatif descriptif afin de mieux comprendre les besoins des personnes atteintes de cancer recevant des SPFV à domicile en milieu rural et d’avoir un portrait des soins et services infirmiers qui leur sont offerts.

Résultats

Cinq personnes atteintes de cancer nécessitant des SPFV en milieu rural ont rapporté de nombreux besoins, notamment en termes de ressources informationnelles restreintes et des nombreux déplacements vers les milieux urbains qui nécessitent de l’organisation et du temps. Pour répondre à ces besoins, sept infirmières offrant des soins et services à domicile en milieu rural décrivent plusieurs défis, notamment les grandes distances à parcourir, les ressources professionnelles spécialisées limitées, les transferts aux urgences, le manque de formation en SPFV et l’absence d’équipe dédiée.

Conclusion

Ces résultats permettent de mieux comprendre des besoins spécifiques des personnes atteintes de cancer nécessitant des SPFV à domicile en milieu rural ainsi que les divers défis auxquels les infirmières font face afin de favoriser le maintien à domicile.

[Nursing and end-of-life care at home in a health crisis]

The Covid-19 pandemic led healthcare professionals to reconsider their work organization and some of their practices, in order to respond to the health emergency and the importance of care needs. While hospital teams managed the most serious and complex health situations, home care workers also made significant efforts to redeploy their rounds, to take care of and accompany patients at the end of their lives and their loved ones while managing hygiene constraints. A nurse looks back on one of these cases and the questions it raised.

[Management of the end of life in the emergency department: evaluation of a dedicated training course on emergency department practices at the CHU Ambroise Paré]

End of life is a common situation in emergency medicine. However, the training of nursing staff seems to be lacking in this area. We studied the impact of dedicated training on the management of end-of-life patients admitted to the adult emergency department of the Ambroise-Paré University Hospital.

[Risks and Opportunities of Reproducing with HIV]

End-of-life support and the implementation of a palliative approach require specific skills deployed in multidisciplinary teams. The same is true for professionals in the disability sector who accompany the life projects of people living in specialized facilities. This article proposes, based on a clinical situation at the end of life, a reflection on the acculturation of practices between the health, social and medico-social fields in favor of better end-of-life support for people with disabilities.

The Quebec Observatory on End-of-Life Care for People with Dementia: Implementation and Preliminary Findings

Most Canadians with dementia die in long-term care (LTC) facilities. No data are routinely collected in Canada on the quality of end-of-life care provided to this vulnerable population, leading to significant knowledge gaps. The Quebec Observatory on End-of-Life Care for People with Dementia was created to address these gaps. The Observatory is a research infrastructure designed to support the collection of data needed to better understand, and subsequently enhance, care quality for residents dying with dementia. This article reports on the main steps involved in setting up the Observatory, as well as a pilot study that involved 172 residents with dementia who died between 2016 and 2018 in one of 13 participating facilities. It describes the data gathered, methodological changes that were made along the way, feedback from participating facilities, and future developments of the Observatory.

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The Snoezelen approach, in the context of residential establishment for dependent elderly people, is beneficial to the resident and his entourage as well as to the care teams. It provides soothing and welfare to the resident and comforts the families, who perceive the relaxation of their loved one. A bond is created around the person at the end of life, opportunity to experience privileged moments.

[Delirium Management in Palliative Care]

Delirium Management in Palliative Care Abstract. Delirium is one of the most common neuropsychiatric complications in patients with advanced incurable disease. End-of-life delirium is common but is often overlooked, undiagnosed or incorrectly diagnosed/untreated. Delirium should also be treated in a palliative situation - as far as possible - because persistent delirious states increase the patient's fragility, limit physical functionality and shorten the lifespan. In addition, acute states of confusion trigger high levels of distress in affected patients and their relatives, impair the quality of life and a dignified dying process. While hallucinations and visions at the end of life are interpreted as delirium in medicine and treated as such, this phenomenon is interpreted by philosophical and theological hermeneutics as a resource that can help patients and their relatives to reconcile with past life events and to deal with the process of dying. However, the occurrence of end-of-life visions as opposed to delirium has not yet been studied very much and requires more detailed exploration.

[Nursing practice and end of life support at home]

Accompanying a person at the end of life at home requires skills to alleviate symptoms and the availability to take care of the person and his or her loved ones. Interdisciplinary teamwork helps to give meaning to the care project and to cross the views on complex issues.

[Prisoners, caregivers and volunteers faced with COVID-19]

An enclosed space with specific constraints, prison authorises volunteers to support seriously ill patients at the end of life. After receiving relevant training, these volunteers become members of an approved association and can enter compounds such as Fresnes penitentiary hospital in Val-de-Marne. While the missions of these volunteers have been disrupted by covid-19, solutions have been put in place to allow the connection with the prisoners to be maintained.

[Influence of COVID-19 on issues relating to end of life and the support of patients]

The covid-19 epidemic and the resulting lockdown measures have undoubtedly led people who are ill, as well as those at risk of becoming ill, to contemplate the notions of risk, uncertainty and death. What effects has this confrontation with the question of death had and what impact will it continue to have on the palliative care approach and the decisions to withhold and withdraw treatment in certain circumstances?

Applying the Knowledge-to-Action Framework to Engage Stakeholders and Solve Shared Challenges with Person-Centered Advance Care Planning in Long-Term Care Homes

As they near the end of life, long term care (LTC) residents often experience unmet needs and unnecessary hospital transfers, a reflection of suboptimal advance care planning (ACP). We applied the knowledge-to-action framework to identify shared barriers and solutions to ultimately improve the process of ACP and improve end-of-life care for LTC residents. We held a 1-day workshop for LTC residents, families, directors/administrators, ethicists, and clinicians from Manitoba, Alberta, and Ontario. The workshop aimed to identify: (1) shared understandings of ACP, (2) barriers to respecting resident wishes, and (3) solutions to better respect resident wishes. Plenary and group sessions were recorded and thematic analysis was performed. We identified four themes: (1) differing provincial frameworks, (2) shared challenges, (3) knowledge products, and 4) ongoing ACP. Theme 2 had four subthemes: (i) lacking clarity on substitute decision maker (SDM) identity, (ii) lacking clarity on the SDM role, (iii) failing to share sufficient information when residents formulate care wishes, and (iv) failing to communicate during a health crisis. These results have informed the development of a standardized ACP intervention currently being evaluated in a randomized trial in three Canadian provinces.

[Nurses in multi-disciplinary team to face Sars-CoV-2 in intensive care]

At the heart of the epidemic wave of spring 2020, the intensive care units faced the surge of patients with severe forms of the disease. To meet the scale of the needs, the care teams were reorganised, reinforced and adapted, as demonstrated by a hospital team specialising in neurology which, beyond the ethical issues, shortages and fears, proceeded to the "covidisation" of its resuscitation and the total reorganisation of the other units, in order to expertly organise care adapted to the needs of the patients. From a distance, and while the epidemic is still active, many questions remain.

[Cystic fibrosis, support and end of life of patients]

Cystic fibrosis is a chronic disease detected at birth that requires multidisciplinary follow-up throughout life. Two singular stories guide us in the reflection on end-of-life care. Firstly, it is a painful stage when it comes to giving up lung transplantation. The care receiver also wants continuity of care in line with his or her philosophy of life. The partnership of the caregivers with the ethical space and/or palliative care of the hospital becomes a necessary third party for a more peaceful end of life.

[End-of-life and advance healthcare directives]

In the context of the care of people at the end of life, the implementation of measures relating to advance healthcare directives still appears to be problematic. A nursing team in Saône-et-Loire carried out a research project on this issue and highlighted several obstacles: poor knowledge of the law, a lack of information among the general public, the sensitivity of the subject, etc. The project revealed avenues for further reflection now being explored.

[Palliative care in a paediatric intrahospital mobile team]

Paediatric palliative care has been set up after extensive discussion and observations regarding the need to provide different support to children with a serious and incurable disease as well as their families. The mobile palliative care team support children and their family in this specific process and train caregivers in the palliative approach.

[Virtual reality and palliative care, a complement in the care provision]

Commonplace in the world of gaming or the cinema, virtual reality headsets have made their appearance in the hospital over recent years. A nursing team in Lyon shares its feedback regarding the benefit of these tools as a complement to the care provided to patients in a palliative care unit.

[Practical aspects of administering midazolam as a sedative]

In a context of an acute complication with immediate threat to life or of a refractory symptom, the administering of a sedative is not a minor procedure for the nursing teams. Titration is an essential and key stage. Focus on the practical aspects of administering midazolam as a sedative to an adult receiving palliative care.

[The decision to withdraw specific treatments in oncology]

Shared medical decision-making is a complex process, especially with regard to the withdrawal of specific treatments in oncology. On the one hand, patients, particularly vulnerable due to their advanced disease, and their family, apprehend this withdrawal. On the other hand, oncologists have more and more treatment options available to them thanks to the medical advances made over recent years. An observational prospective study was carried out in oncology. It focused on the motives which led to the question of treatment withdrawal being raised, to the degree of agreement between the different parties (palliative care team, oncologist, patients and families) and on the final decision.

[Shared medical decision-making at the end of life, the role of the home health nurse]

Caring for patients approaching the end of life in their home requires multidisciplinary reflection on the part of all caregivers. Informing the patients and their families as well as taking into consideration all aspects of the support needed must lead to decisions being made as a team. Global care can then be provided based on a joint care project.

[Shared decision-making and end of life in a nursing home]

The decision-making process in a nursing home is complex. In view of the prevalence of cognitive disorders and the importance of the role of carers, the personal choice becomes more of a shared decision. The legal framework, while favourable, remains under-used and could be improved.

[Patient-caregiver transference in patients at the end of life]

The question of transference has been extensively covered in nursing literature. Faced with a patient approaching the end of life, caregivers, emotionally shaken, sometimes lose their therapeutic bearings. By drawing on the principles of countertransference, they can support these patients with all the necessary empathy, without becoming lost in the complexity of transference issues.

[Music therapy in paediatric oncology]

At Gustave Roussy Institute in Villejuif, musicians regularly work with hospitalised children. Music offers young patients and their family a moment of wellbeing. The caregivers also appreciate this tool which can help to facilitate difficult care procedures.

[A small dose of impertinence in end-of-life care at home]

The patient-centred palliative care approach means establishing partnerships between him or her, the caregivers, the family, social sector professionals and care volunteers. Communication, which takes the form of dialogue, listening, establishing a relationship of trust and observing behaviour and body language is essential faced with the uncertainty and existential questioning of the patient and their family. In the patient's home, as this experienced nurse describes, this questioning leads caregivers to reflect on their professionalism and humanity.

An Analysis of Documents Guiding Palliative Care in Five Canadian Provinces

ABSTRACTThe purpose of this study was to analyse the consistency and extent of palliative content across high-level guiding documents related to the care of persons residing in Canadian long-term care homes. A systematic search was conducted examining documents at the national level and across five provinces (Alberta, Ontario, Saskatchewan, Manitoba, and Quebec). Twenty-five documents were selected based on inclusion criteria from 273 documents identified in the systematic search. The majority of these documents were created nationally (48%) or in Ontario (28%). Documents varied in palliative topics discussed, and long-term care was discussed minimally. A minimal number of palliative care guiding documents were found. Long-term care specific documents were absent, and all documents lacked consistency on palliative topics. It is imperative that palliative principles are present and consistent in high-level documents in order to improve the quality of life and care for long-term care residents across Canada.

Caregiver Out-of-Pocket Costs for Octogenarian Intensive Care Unit Patients in Canada

ABSTRACTMedical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.

[Preventive approach of oral care for comfort and hydration]

The risk of deterioration of oral health is increased in the palliative phase of a disease due to the drying out of the oral mucosa by the treatments. Weakened, the patient drinks and eats little, or not at all. Caregivers therefore need to take over the patient's oral care to ensure hygiene and comfort. As a preventive approach, providing mouth care for hydratation and comfort associated with oral hygiene are essentials.

[Beating cancer, living with it: success and ethical dilemmas]

Cancers are serious conditions which affect numerous families. The advances made in treatments thanks to research enable a growing number of cancers to be cured. Some cancers which are treated evolve towards a form of chronicity whereby patients have to live with the condition. These varied situations, always sensitive, mobilise and bring together patients, their families, caregivers, researchers and associations. There are many ethical dilemmas facing all those involved in this fight.

[Organising and supporting the end of life when faced with a refusal of care]

Often ethically complex, end-of-life situations can mean nursing teams are confronted with a refusal of care. Through a representative clinical situation, a nurse describes the support provided by a multidisciplinary team, in the home, to comply with the wishes of a person at the end of life, support the family, anticipate possible difficulties and organise adapted care which respects all those concerned.

[Psychiatry and palliative care, collaboration for the benefit of the patient]

As palliative care units continue to develop, the provision of end-of-life care for patients with a chronic mental illness needs to be addressed. Aside from the somatic comorbidities to which these patients are particularly exposed and in view of the specificity of psychiatric treatment, the forms of end-of-life support for a patient with schizophrenia are described here, based on the experience of a psychiatric unit in the Var region.

[Private practice nurse and palliative care in the home]

The development of palliative care in the home, requested by patients and recommended in the 2015-2018 national plan, requires the home to be considered as a specific place of care. Private practice nurses have an important role to play with the patient and their relatives, in the assessment of needs, coordination, relational care as well as in providing the care required for maintaining and continuing life, an increasingly technical process.

Broadening End-of-Life Comfort to Improve Palliative Care Practices in Long Term Care

This study aimed to (1) explore how palliative care in long-term care (LTC) addresses the tensions associated with caring for the living and dying within one care community, and (2) to inform how palliative care practices may be improved to better address the needs of all residents living and dying in LTC as well as those of the families and support staff. This article reports findings from 19 focus groups and 117 participants. Study findings reveal that LTC home staff, resident, and family perspectives of end-of-life comfort applied to those who were actively dying and to their families. Our findings further suggest that eliciting residents' perceptions of end-of-life comfort, sharing information about a fellow resident's death more personally, and ensuring that residents, families, and staff can constructively participate in providing comfort care to dying residents could extend the purview of end-of-life comfort and support expanded integration of palliative principles within LTC.

[The wounds of people receiving end-of-life palliative care]

When it includes the care of wounds, the management of patients at the end of life mobilises caregivers around a care project which brings together therapeutic, technical and relational challenges. In partnership with the patient and their families, the care must be adjusted and respectful of the patient's progression.

Stakeholder Meeting: Integrated Knowledge Translation Approach to Address the Caregiver Support Gap

Family caregivers are an integral and increasingly overburdened part of the health care system. There is a gap between what research evidence shows is beneficial to caregivers and what is actually provided. Using an integrated knowledge translation approach, a stakeholder meeting was held among researchers, family caregivers, caregiver associations, clinicians, health care administrators, and policy makers. The objectives of the meeting were to review current research evidence and conduct multi-stakeholder dialogue on the potential gaps, facilitators, and barriers to the provision of caregiver supports. A two-day meeting was attended by 123 individuals. Three target populations of family caregivers were identified for discussion: caregivers of seniors with dementia, caregivers in end-of-life care, and caregivers of frail seniors with complex health needs. The results of this meeting can and are being used to inform the development of implementation research endeavours and policies targeted at providing evidence-informed caregiver supports.

[Working in a team around nursing values]

Particularly interested in the relational aspect of care, Stéphanie Liénard became a nurse at the age of 36. She began her nursing career in a prison and now works in the field of end-of-life care.

[Organ and tissue donation after cessation of treatment in intensive care, the role of the nurse coordinator]

Since the end of 2014 in France, it has been possible to remove organs after a process of cessation of active treatment. This new procedure requires rigorous and well-managed organisation, as well as close collaboration between all those involved in the care, notably in the coordination of organ and tissue procurement.

[The anticipated organ donation approach in hospital]

In end-of-life situations it is important to avoid futile transfers to intensive care and to respect the wishes of the patient. To this end, it is possible to talk about the approaching death and organ donation with the family, in an 'anticipated' support approach.

[End of life and vulnerability, a public health issue]

End of life and precarity, two words which were linked by the French national observatory for end of life care in its work carried out in 2014. The study provided an overview of current support practices in different areas, highlighting certain lessons to be learned and making recommendations to the different partners involved.

[The "wine bar", or a different way of caring]

The "wine bar" in the palliative care unit of Clermont-Ferrand general hospital is an example of a different way of providing care. It defends the right of patients at the end of life to treat themselves and others. Acknowledging that life is present right up until the end, patients are invited to drink wine at mealtimes and caregivers are encouraged to learn the basics of oenology.

[The nursing role and ethical dimension of end of life care]

Supporting people in situations of precarity at the end of life is often fraught with complex problems, where one form of vulnerability amplifies another. This complexity requires interdisciplinary support, around the nursing care, to reflect together on the meaning of the action taken in an ethical approach.

[Hospital perspectives on the end of life, the case of homeless people]

The hospital is the last refuge for sick homeless people when their illness makes life on the street impossible. The teams often consider these patients as different, difficult and not easy to place in a specific type of care. In palliative care, fewer questions are raised as the patients are hospitalised for their terminal phase. The difficulties often lie in diagnosing the disease and recognising its seriousness and the patient's social situation.